A nurse is caring for a victim of domestic violence. What charting by the nurse is most appropriate?
a. Patient allegedly beat up by her boyfriend.
b. Patient has several bruises on the legs.
c. Patient states, "My boyfriend hit me with a hammer."
d. Patient claims she was assaulted last night.
ANS: C
Good charting is objective and detailed. Using the patient's own words, in quotation marks, is the most accurate example of documentation. The nurse should not use words like "allegedly" or "claims" because they seem to cast doubt on the patient's story. The bruises on the legs need to be measured and described more fully.
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An older client is diagnosed with hemolytic anemia. What will the nurse teach the client about this disorder?
1. It is caused by blood loss. 2. It will be treated with folic acid. 3. It causes the red blood cells to be misshaped. 4. It is associated with decreased immature red blood cells.
The nurse is caring for a patient pregnant with twins. Which statement indicates that the patient needs additional information?
1. "Because both of my twins are boys, I know that they are identical." 2. "If my twins came from one fertilized egg that split, they are identical." 3. "If I have one boy and one girl, I will know they came from two eggs." 4. "It is rare for both twins to be within the same amniotic sac."
An elderly patient is going through drug and alcohol withdrawal, suffering from hallucinations followed by loud emotional outbursts. A nurse identifies this condition as
1. Dementia. 2. Delirium. 3. Depression. 4. Confusion.
Which documentation indicates that the treatment plan for a patient with acute mania has been effective?
a. "Converses without interrupting, clothing matches, participates in activities." b. "Irritable, suggestible, distractible, napped for 10 minutes in afternoon." c. "Attention span short, writing copious notes, intrudes in conversations." d. "Heavy makeup, seductive toward staff, pressured speech."